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Vectorborne Zoonoses: Break-Out Session Epidemiology and Laboratory Capacity Workshop – Oct

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Vectorborne Zoonoses:

Break-out Session

Epidemiology and Laboratory

Capacity Workshop – Oct. 2018

DSHS Zoonosis Control Branch

Session Topics

• NEDSS case investigation tips • Lyme disease • Rickettsial diseases • Arboviral diseases

  • ELC 2018 - Vectorborne Diseases
  • 2

Don’t be a Reject!

Helpful tips to keep your notification from being rejected

ELC breakout session
October 3, 2018

Kamesha Owens, MPH Zoonosis Control Branch Texas Department of State Health Services

Objectives

• Rejection Criteria • How to document in NBS

(NEDSS)

• How to Report

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Rejection Criteria

Missing/incorrect information:

• Incorrect case status or

condition selected
• Full Name

• Date of Birth

• Address • County

• Missing laboratory data

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Rejection Criteria

continued

• Inconsistent information

• e.g. Report date is a week

before onset date

• Case investigation form not

received by ZCB within 14 days of notification

• ZCB recommends that notification

not be created until the case is

closed and the investigation form has been submitted

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Rejection Criteria

continued

• Condition-specific information

necessary to report the case is

missing: • Travel history for Zika and other non-endemic conditions

• Evidence of neurological disease for WNND case

• Supporting documentation for

Lyme disease case

determination

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How to Document in

NBS (NEDSS)

Do

Don’t

Add detailed comments in designated

comments box under case info tab.

Leave us guessing!

If you decide not to enter comments,

(strongly recommended not required) please make sure information on

paper form is legible.

Ensure all fields required to be entered are filled in or selected.
Leave important fields blank, i.e. symptoms, lab results, date of
• Check your dates (Onset date, date report, etc. of report, etc.) to ensure the timeline reflected makes sense and is accurate.(See DEG for details)

Check NBS entry against paper form to make sure the information is the same.

Leave out Condition-specific

information necessary to report a

case (i.e. travel dates and history for

Zika cases).

Enter a comment in ALL positive ELRs

for non-cases explaining why the case-
Leave positive ELRs comments section blank or not associate relevant patient does not meet case definition or is appropriate labs to case

“lost to follow-up” (LTF) unless the ELRs

investigations. are associated with an NBS investigation.

  • 10/3/2018
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Reporting Zoonoses

• For LHDs: Scan and attach,

fax, or send via secure e-mail the completed investigation

form with relevant lab reports

to your Regional ZC office for review

• After review, the Regional ZC

staff will forward to ZCB Central Office for final review

and approval

  • 10/3/2018
  • ELC 2018 - Vectorborne Diseases

9

Reporting Zoonoses

For ZC Regional Staff:

Scan and attach, fax, or send via secure e-mail completed

case investigation form with

relevant lab reports to Central Office ZCB epidemiologists for

review and approval

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  • ELC 2018 - Vectorborne Diseases

10

Attaching Documents

in NEDSS

• Not all Conditions allow this

• Scan/Save the completed form and

laboratory reports as a pdf

• Attach the document under the

Supplemental Info tab of the case investigation

• Scroll down until you see “Attachments”

under the “Notes and Attachments”

section, then click on the button that is

labeled “Add Attachment”

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Resources

• TDSHS Zoonosis website:

http://www.dshs.texas.gov/idcu/ health/zoonosis/

• IDCU:

http://www.dshs.texas.gov/idcu/ default.shtm

• NBS Data Entry Guide (DEG):

https://txnedss.dshs.state.tx.us:8009/ PHINDox/UserResources/

• Epi Case Criteria Guidelines (ECCG):

https://txnedss.dshs.state.tx.us:8009/

PHINDox/UserResources/

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Lyme Disease

Case Classification and

Two-Tiered Testing

Bonny Mayes, MA, RYT

Epidemiologist

Zoonosis Control Branch Department of State Health Services Austin, Texas

Lyme Disease

Causative Agent: Spirochete bacterium Borrelia

burgdorferi sensu stricto in US (5 other Borrelia sp in

Europe or Asia) Vectors: Blacklegged tick (deer tick), Ixodes scapularis,

and western blacklegged tick, Ixodes pacificus, on Pacific

Coast

Incubation Period: 3-32 days after exposure (mean 7-

10 days) for EM rash and/or flu-like symptoms

Transmission: Transmission generally does not occur

until after tick has been attached for at least 36 hours

  • ELC 2018 - Vectorborne Diseases
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The Enzootic Cycle of Borrelia burgdorferi

www.nature.com/nrmicro/journal/v10/n2/fig tab/nrmicro2714 F1.html

15

ELC 2018 - Vectorborne Diseases

Lyme Disease

Clinical Presentation

A systemic, tickborne disease with protean manifestations, including dermatologic, rheumatologic, neurologic, and cardiac abnormalities. The best clinical marker for the disease is the initial skin lesion, erythema migrans (EM). For most patients, the expanding EM lesion is accompanied by

other acute symptoms, particularly fatigue, fever, headache,

mildly stiff neck, arthralgia, or myalgia.

www.cdc.gov/lyme/signs_symptoms/index.html

16

ELC 2018 - Vectorborne Diseases

Erythema Migrans (EM) Rash

www.cdc.gov/lyme/signs_symptoms/index.html

• Occurs in approximately 70 to 80 percent of infected persons

• Begins at the site of a tick bite after a delay of 3 to 30 days (average is about 7 days)
• Expands gradually over a period of days reaching up to 12 inches or more (30 cm) in diameter

• May feel warm to the touch but is rarely itchy or painful

• Sometimes clears as it enlarges, resulting in a target or “bull's eye”

appearance
• May appear on any area of the body

• Annular erythematous lesions occurring within several hours

of a tick bite represent hypersensitivity reactions and do not

qualify as EM!

Lyme Disease rashes and Look alikes: www.cdc.gov/lyme/signs_symptoms/rashes.html

Itchy rash due to insect bites

“classic” Lyme disease rash

17

ELC 2018 - Vectorborne Diseases

Lyme Disease

2018 Case Definition/Case Classification

Confirmed: A case with physician diagnosed EM ≥ 5 cm in size with

an exposure in a high-incidence state or country*,

OR a case of physician diagnosed EM ≥ 5 cm in size with laboratory

confirmation with an exposure in a low-incidence state or country*,

OR a case with at least one late manifestation that has laboratory confirmation.

*Exposure is defined as having been (≤ 30

days before onset of EM) in wooded, brushy, or grassy areas (i.e., potential tick habitats). An exposure in a high-incidence state is defined as exposure in a state with

an average Lyme disease incidence of at

least 10 confirmed cases/100,000 persons for the previous three reporting years. A low-incidence state is defined as a state with disease incidence of <10 confirmed cases/100,000 persons for the previous

three reporting years.

www.cdc.gov/lyme/stats/tables.html

Texas is considered a low incidence state for Lyme disease!

  • ELC 2018 - Vectorborne Diseases
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Lyme Disease
High Incidence Areas

• Most commonly reported

vector-borne illness in the United States
• Does not occur nationwide and

is concentrated heavily in the

northeast and upper Midwest

High Incidence States:

Connecticut, Delaware, Maine,

Maryland, Massachusetts,

Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia,

Wisconsin

www.cdc.gov/lyme/stats/index.html

Outside of the US

Lyme disease is common in some forested areas in Europe. Countries

with highest reported incidence include Germany, Austria, Slovenia,

and Sweden.*

*Infectious Disease Clinics of North America, Vol. 22/Ed. 2, Fish AE, Pride YB, Pinto DS, Lyme carditis, 275-288

  • ELC 2018 - Vectorborne Diseases
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Lyme Disease

2018 Case Definition/Case Classification

Confirmed: A case with physician diagnosed EM ≥ 5 cm in size with

an exposure in a high incidence state or country,

OR a case of physician diagnosed EM ≥ 5 cm in size with laboratory

confirmation with an exposure in a low incidence state or country,

OR a case with at least one late manifestation* that has laboratory confirmation.

  • ELC 2018 - Vectorborne Diseases
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    Emerging Infectious Diseases is indexed in Index Medicus/Medline, Current Contents, and several other electronic databases. Liaison Representatives Editors Anthony I. Adams, M.D. William J. Martone, M.D. Editor Chief Medical Adviser Senior Executive Director Joseph E. McDade, Ph.D. Commonwealth Department of Human National Foundation for Infectious Diseases National Center for Infectious Diseases Services and Health Bethesda, Maryland, USA Centers for Disease Control and Prevention Canberra, Australia Atlanta, Georgia, USA Phillip P. Mortimer, M.D. David Brandling-Bennett, M.D. Director, Virus Reference Division Perspectives Editor Deputy Director Central Public Health Laboratory Stephen S. Morse, Ph.D. Pan American Health Organization London, United Kingdom The Rockefeller University World Health Organization New York, New York, USA Washington, D.C., USA Robert Shope, M.D. Professor of Research Synopses Editor Gail Cassell, Ph.D. University of Texas Medical Branch Phillip J. Baker, Ph.D. Liaison to American Society for Microbiology Galveston, Texas, USA Division of Microbiology and Infectious University of Alabama at Birmingham Diseases Birmingham, Alabama, USA Natalya B. Sipachova, M.D., Ph.D. National Institute of Allergy and Infectious Scientific Editor Diseases Thomas M. Gomez, D.V.M., M.S. Russian Republic Information and National Institutes of Health Staff Epidemiologist Analytic Centre Bethesda, Maryland, USA U.S. Department of Agriculture Animal and Moscow, Russia Plant Health Inspection Service Riverdale, Maryland, USA Bonnie Smoak, M.D. Dispatches Editor U.S. Army Medical Research Unit—Kenya Stephen Ostroff, M.D. Richard A. Goodman, M.D., M.P.H. Unit 64109 National Center for Infectious Diseases Editor, MMWR Box 401 Centers for Disease Control and Prevention Centers for Disease Control and Prevention APO AE 09831-4109 Atlanta, Georgia, USA Atlanta, Georgia, USA Robert Swanepoel, B.V.Sc., Ph.D.
  • Rocky Mountain Spotted Fever

    Rocky Mountain Spotted Fever

    Spotted Fevers Importance Spotted fevers, which are caused by Rickettsia spp. in the spotted fever group (including (SFG), have been recognized in people for more than a hundred years. The clinical signs are broadly similar in all of these diseases, but the course ranges from mild and Rocky Mountain self-limited to severe and life-threatening. For a long time, spotted fevers were thought to be caused by only a few organisms, including Rickettsia rickettsii (Rocky Spotted Fever Mountain spotted fever) in the Americas, R. conorii (Mediterranean spotted fever) in the Mediterranean region and R. australis (Queensland tick typhus) in Australia. and Many additional species have been recognized as human pathogens since the 1980s. Mediterranean These infections are easily misidentified with commonly used diagnostic tests. For example, some illnesses once attributed to R. rickettsii are caused by R. parkeri, a less Spotted Fever) virulent organism. Animals can be infected with SFG rickettsiae, and develop antibodies to these organisms. With the exception of Rocky Mountain spotted fever and possibly Mediterranean spotted fever in dogs, there is no strong evidence that these organisms Last Updated: November 2012 are pathogenic in animals. It is nevertheless possible that illnesses have not been recognized, or have been attributed to another agent. Rocky Mountain spotted fever, which is a recognized illness among dogs in the North America, was only recently documented in dogs in South America. Etiology Spotted fevers are caused by Rickettsia spp., which are pleomorphic, obligate intracellular, Gram negative coccobacilli in the family Rickettsiaceae and order Rickettsiales of the α-Proteobacteria. The genus Rickettsia contains at least 25 officially validated species and many incompletely characterized organisms.